Pivot Shift

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Definition/Description[edit | edit source]

The pivot shift is a dynamic test of knee stability, passively carried out by the examiner. The movement is a combination of axial load and valgus force, applied by the examiner, during knee flexion from an extended position. When the test is positive, it indicates an injury of the anterior cruciate ligament. [1][2]

This test is analogous to Slocum's Test, which is carried out with the patient in side-lying. [3]

Clinically Relevant Anatomy[edit | edit source]

-Knee diagram.svg.png

The knee joint or articulatio genus is the biggest and most complicated synovial joint in the human body. It’s formed by the distal end of the femur and the proximal end of the tibia. Between these two, the medial and lateral meniscus are located. The anterior part of the femur (facies patellaris femoris) articulates with the patella which forms the patellofemoral joint. The cruciate ligaments, situated in the intercondylar space, and the collateral ligaments, are important ligaments in the knee.


The anterior cruciate ligament (ACL) arises from the anterior intercondylar area of the tibia, which is posterior to the attachment of the medial meniscus. This ligament extends upwards, dorsally, and laterally to attach to the posterior aspect of the medial part of the lateral condyle of the femur. It limits posterior rolling, turning and travelling, of the femoral condyles on the tibial plateau during flexion, thus causing it to turn in place. It also prevents posterior shifting of the femur on the tibia, or the tibia from moving anteriorly, and prevents hyperextension of the knee. With the knee joint flexed at 90o, and the ACL fully intact, the tibia cannot be pulled anteriorly, since it is held by the ACL. [4]


The posterior cruciate ligament (PCL) is stronger than the ACL. It run from the posterior intercondylar area of the tibia, passes superiorly and anteriorly medially to the ACL, and attaches to the anterior part of the lateral surface of the of the medial condyle of the femur. The PCL prevents forward rolling of the femur on the tibial plateau during extension, thus causing it to spin. It also prevents anterior movement of the femur on the tibia, which can be thought of as posterior movement of the tibia on the femur. It also helps prevent hyperflexion of the knee joint. When the knee is flexed, in weight-bearing, as when walking downhill, the femur is mainly stabilized by the PCL. [4]

Purpose[edit | edit source]

The purpose of this test is to detect anterolateral rotary instability of the knee. This test is used in chronic conditons and is positive when the ACL is torn. The ALC can also be torn. [3]

Technique[edit | edit source]

The following steps explain how the test is carried out: [3]

  1. The patient lies supine with legs relaxed.
  2. The therapist presses against the head of the fibula with one hand, and grasps the ankle with the other hand.
  3. The lower leg is passively internally rotated, while the knee is kept in full extension.
  4. The hip is flexed to 30 degrees, while the knee is flexed.
  5. A valgus force and axial load are applied to the knee at the same time.
  6. Upon damage to the ACL, there will be subluxation of the lateral tibial plateau in the fully extended position.
  7. When the knee is flexed between 20o and 40o, the lateral tibial plateau will reduce itself, and a palpable shift or clunk will be noticed.

See the following videos for an explanation of the Pivot Shift Test:

[5]
[6]

Interpretation[edit | edit source]

A positive test is indicated by subluxation of the tibia while the femur rotates externally, followed by a reduction of the tibia at 30-40 degrees of flexion. [3]

Evidence[edit | edit source]

Is the pivot shift test a reliable test?
The Pivot Shift test attempts to reproduce the rotary and translatory instability in an ACL deficient knee. [7] The test has a sensitivity from 0.18 to 0.48 and a specificity from 0.97 to 0.99 for diagnosing an ACL tear. The mean sensitivity and specificity values are 0.32 and 0.98, respectively. [8] [9] [10] Although the test is clinically relevant and reproduces a functional movement of the knee joint, it is difficult to quantify.

Recently a study was done using a navigation system to quantify measurements of knee laxity in individuals who underwent ACL reconstruction. The Pivot shift test was reliable with both patient self-assessment of laxity and with surgical performance. [11] This highlights the clinical relevance of the test. Traditionally, the Lachman's Test or the less significant Anterior drawer test were used more often to measure knee laxity due to its quantifiability. However, recent advances in technology have allowed for more objective and measurable observations of the motions involved in the pivot shift and may lead to the ability to make the test quantifiable for research. [12]

Grading the pivot shift 

“A number of variations of the basic pivot shift test also have been described (Hugston et al. 1976; Slocum et al. 1976; Losee, Johnson and Southwick 1978; Galaway and MacIntosh 1980). All these variations indicate anterior translation and rotational subluxation of the tibia on the femur.” [2]

For the pivot shift test, the examiner applies an axial and valgus load with one hand. This hand also controls the rotational position of the tibia during the test. With the other hand, the foot is held firmly against the examiner.
The test can be carried out in three positions of rotation: medial, neutral, and lateral rotation of the tibia. [2]

Table 1. shows the displacement of the medial and lateral plateau of the knee, comparing different grades of severity of an injured knee in accordance with the pivot shift test. [2]
Table 1

Pivot shift Normal knee Grade I Grade II Grade III
Medial plateau 3mm 5mm 10mm 15mm
Lateral plateau 5mm 12mm 18mm 22mm

Remark: the lateral side of the tibia plateau is always the most mobile.


Table 2. Shows the subluxation of the knee, comparing different grades of severity of an injured knee in accordance with the Lachman test [2]

Lachman Grade I Grade II Grade III

9mm 10-15mm >15mm

                                                                                                                                                    

Clinical Bottom Line[edit | edit source]

The meaning of the test, in determining the clinical significance, is that the different grades of the test can define the level and direction of the laxity, which have been called anteromedial, anterolateral, and posterolateral. This results in a visualisation of the progression in chronic anterior cruciate injury. This is due to the successive use of the three positions of the tibial rotation. [2]

The pivot shift test has been established to be the most specific test for ACL tears [9].

References[edit | edit source]

  1. ↑ Musahl V, Citak M, O’Loughlin P.F, Choi D, Bedi A, Pearle A.D. The effect of medial versus lateral menisectomy on the stability of the anterior cruciate ligament-deficient knee. American Journal of Sports Medicine. 2010:38(8):1591-1597.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Jakob R.P, Staubli H.U, Deland J.T. Grading the pivot shift, objective tests with implications for treatment. Journal of Bone and Joint Surgery - British Volume. 1987:69(2):294-299.
  3. ↑ 3.0 3.1 3.2 3.3 Prentice W.E. Principles of Athletic Training - A Competency Based Approach. Thirteenth Edition. New York: McGraw-Hill Higher Education, 2009. p.654-669.
  4. ↑ 4.0 4.1 Moore K.L, Dalley A.F. Clinically Oriented Anatomy. Fifth Edition. Philadelphia: Lippincott Williams & Wilkins, 2006. p690.
  5. ↑ The Knee Resource. Pivot Shift Test. Available from: https://www.youtube.com/watch?v=inPx9dwQuYE&ab_channel=TheKneeResource (accessed 21/05/2024).
  6. ↑ AMBOSS: Medical Knowledge Distilled. Pivot Shift Test - Clinical Examination. Available from:https://www.youtube.com/watch?v=JyT-7-fqW2w&ab_channel=AMBOSS%3AMedicalKnowledgeDistilled (accessed 17/05/2024).
  7. ↑ Lane C.G, Warren R, Pearle A.D. The Pivot Shift. Journal of American Academy in Orthopedic Surgery. 2008:16(12):679-688.
  8. ↑ Briggs K.K, Lysholm J, Tegner Y, Rodkey W.G, Kocher M.S, Steadman J.R. The Reliability, Validity, and Responsiveness of the Lysholm Score and Tegner activity scale for Anterior Cruciate Ligament Injuries of the Knee: 25 years later. The American Journal of Sports Medicine. 37:890-897.
  9. ↑ 9.0 9.1 Prins M. The Lachman test is the most sensitive and the pivot shift the most specific test for the diagnosis of ACL rupture. Australian Journal of Physiotherapy. 2006:8: 52(1):66.
  10. ↑ Ostrowski JA. Accuracy of 3 Diagnostic Tests for Anterior Cruciate Ligament Tears. Journal of Athletic Training. 2006:41(1):120–121.
  11. ↑ Lopomo N, Zaffagnini N, Bignozzi S, Visani A, Marcacci M. Pivot Shift Test: Analysis and Quantification of Knee Laxity Parameters using a Navigaion System. Journal of Orthopaedic Research. 2010:28(2):164-169.
  12. ↑ Katz J.W, Fingeroth R.J. The Diagnostic Accuracy of Ruptures of the Anterior Cruciate Ligament comparing the Lachman Test, the Anterior Drawer Sign, and the Pivot Shift Test in Acute and Chronic Knee Injuries. American Journal of Sports Medicine. 1986:14(1):88-91.
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